Provider Demographics
NPI:1346398682
Name:MALDONADO, LISA M
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:M
Last Name:MALDONADO
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:LISA
Other - Middle Name:M
Other - Last Name:MALDONADO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:3 GOLF VIEW DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE HILL
Mailing Address - State:PA
Mailing Address - Zip Code:19444-1747
Mailing Address - Country:US
Mailing Address - Phone:610-526-0563
Mailing Address - Fax:610-940-0117
Practice Address - Street 1:3 GOLF VIEW DR
Practice Address - Street 2:
Practice Address - City:LAFAYETTE HILL
Practice Address - State:PA
Practice Address - Zip Code:19444-1747
Practice Address - Country:US
Practice Address - Phone:610-526-0563
Practice Address - Fax:610-940-0117
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD040338L2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1140490Medicare ID - Type Unspecified
PAE642240Medicare UPIN